Transcatheter arterial embolization (TAE) of relevant branches of the external carotid artery has been performed to manage intractable oronasal hemorrhage following craniofacial trauma. Of 129 patients with basilar skull fracture, facial fracture, or penetrating injury of head and neck, we evaluated the records of seven with intractable oronasal hemorrhage for whom TAE was considered to be indicated. All three non-survivors had severe traumatic brain injury, although only one of four survivors had severe traumatic brain injury. Non-survivors had a higher plasma d-dimer level than survivors. All three non-survivors died of hemorrhagic shock due to oronasal hemorrhage ; one during and two prior to TAE. TAE should be performed immediately for intractable oronasal hemorrhage following craniofacial trauma. In the presence of severe abnormality of coagulation and fibrinolysis systems due to traumatic brain injury, external carotid artery ligation should be considered as an alternative treatment for intractable traumatic oronasal hemorrhage.
【Aim】There is no clear information regarding whether patients with orthopedic emergency injuries that require urgent revascularization are transported to the hospital within the permissible time of ischemia. We aimed to compare the transportation time via ambulance and via helicopter.【Methods】We compared the cases of 17 patients who were transported via ambulance with those of 18 patients transported via helicopter after sustaining severe injuries on the extremities such as cutting of the finger, and upper and lower limb amputations. The age, sex, injury time, field departure time, hospital arrival time, operating room entry time, injury location, and distance to the hospital were considered as study items, and investigated retrospectively.【Results】In the ambulance group, the transportation time from injury to hospital arrival was approximately 120 minutes for 20 km. In the helicopter group, the transportation time from injury to hospital arrival was approximately 120 minutes for 80 km.【Conclusions】We found that within a range of 80 km from our hospital, the helicopter can transport injured patients requiring emergency care and urgent revascularization within 120 min, the permissible time of ischemia.
Arterial embolization after hemostatic laparotomy is useful for severe liver damage with unstable hemodynamics. Here, we examined angiography after peri-hepatic packing. Between January 2011 and March 2017, eleven patients were directly transported to our center and perihepatic packing was performed as damage control surgery for severe liver damage (AAST-OIS grade IV or higher). All patients required high-priority surgeries, and the time from arrival at the hospital to the initiation of surgery was 47 minutes (median). There were 4 patients for whom computed tomography (CT) was performed before angiography. Although there was no significant difference in the time to the initiation of angiography examination or the time of surgery with or without CT, the initiation of surgery was delayed by approximately 40 minutes in the CT group. Embolization was required for all patients regardless of whether CT was performed.
Damage control is a treatment strategy focused on hemorrhage and contamination control, followed by definitive repair at a later time-point. A similar strategy is followed for the management of pediatric cases. We report the case of a 6-year-old boy who developed cardiac arrest after blunt abdominal trauma and was managed using damage control surgery. Spontaneous circulation was restored before hospital admission, and he survived without any neurological deficit after multiple damage control laparotomies. Clinicians should be aware that appropriate intervention using a damage control strategy is necessary for the management of pediatric cases.
We report a case of urogenital injury due to blunt trauma. The patient was a 64-year-old woman who was injured in a traffic accident. Computed tomography revealed active hemorrhage around a left ovarian tumor. Upon insertion of the urinary catheter, gross hematuria was observed. Emergency laparotomy was performed, which revealed that the mesentery, left broad ligament of the uterus, and bladder were injured. The patient recovered well post-surgery, and was transferred to the rehabilitation hospital on day 53 post-injury. Although urogenital injury is uncommon, in this case, the ovarian tumor may have exerted pressure on the broad ligament of the uterus, which in turn, ruptured the bladder.
Case 1 was a 50-year-old man who was in shock after a traffic accident. Resuscitative endovascular balloon occlusion of the aorta (REBOA) was performed to stabilize the hemodynamics, and the following contrast CT enabled diagnosis of open pelvic fracture, open left femoral fracture, rectal injury, and popliteal artery injury. After repair of the popliteal artery, colostomy was performed. Case 2 was a 12-year-old boy who was in shock after a traffic accident. After REBOA was performed, contrast CT revealed open pelvic fracture, rectal injury, and urethral injury. He underwent a vascular embolization procedure, followed by colostomy. Both patients were successfully treated without pelvic sepsis. REBOA was useful to control bleeding in patients with open pelvic fracture for whom it is important to make an early diagnosis of adjacent organ injury and plan an appropriate treatment strategy.
We report a case of traumatic extraperitoneal rupture that required surgical treatment in the subacute phase. A 69-year-old woman was transported to our hospital following a traffic injury. Intraperitoneal bladder rupture, pelvic fracture, aortic injury, right hemothorax, and left tibiofibular fracture were observed, and emergency bladder repair surgery was performed. Retrograde cystography performed on hospital day 14 confirmed new extraperitoneal leakage of contrast medium. Abdominal CT performed on hospital day 27 revealed dehiscence of the bladder wall where it contacted the hematoma around the left pubis and ischium. Cystoscopy performed on hospital day 34 revealed a defect in the left anterior bladder wall. We determined the possibility of natural closure to be low and therefore performed bladder repair surgery. When extraperitoneal bladder injuries come in contact with hematomas, clinicians need to consider the possibility of communication with the bladder as the hematoma is absorbed.
Until recently, treatment for subclavian arterial injuries was mainly performed by surgeons. However, endovascular repair cases for subclavian arterial injury have been recently increasing. At our hospital, we treated four cases of subclavian arterial injuries between 2012 and 2014. In two of the four cases, we performed endovascular repair using bare-metal stents. For the other two cases, we used covered graft stents. Currently, patency is maintained and there have been no major complications. We must carefully assess the results of stent treatment as compared with surgery and the need for antithrombotic drugs. Stent treatments for subclavian arterial injuries are useful from the perspective minimally-invasive treatment.
A 65-year-old man presented to our hospital after sustaining multiple injuries in a motor vehicle accident. Computed tomography angiography demonstrated dissection and stenosis from the proximal left subclavian artery to immediately proximal to the origin of the vertebral artery. Although he had no clinical symptoms, he underwent endovascular treatment for the left subclavian artery injury to prevent distal embolization to the posterior circulation. After placement of an embolic protection device in the left vertebral artery to prevent embolization during the treatment, a stent graft was placed in the proximal left subclavian artery. Postoperative magnetic resonance imaging revealed acute cerebellar infarctions, suggesting that they had occurred asymptomatically during the perioperative period. Urgent endovascular treatment is essential in cases of proximal subclavian artery injury as they may cause fatal cerebral infarctions.
BACKGROUND : Delayed small bowel perforation occurring weeks after blunt abdominal trauma is rare. CASE PRESENTATION : 1) A 49-year-old man was trapped under an iron sheet while at work. He reported severe pelvic pain and shock. Computed tomography (CT) demonstrated small bowel and sigmoid mesenteric injury, and pelvic fracture without extravasation. Transcatheter arterial embolization was performed for pelvic hemorrhagic shock. After 15 days, a fistula between the small bowel and sigmoid was noted on CT. 2) A 70-year-old woman was a restrained driver in a road traffic accident. Her abdominal wall exhibited seat belt marks and injuries, but she reported no abdominal pain. CT revealed small bowel mesenteric injury and Chance fracture. After 10 days, an air leak in the small bowel mesentery was noted on CT. CONCLUSION : A direct blow with compression forces and local ischemia causing mesenteric injury may induce delayed small bowel perforation.
A 22-year-old man was trapped under a car and sustained injuries. His initial cardiac rhythm was asystole. Return of spontaneous circulation was achieved 63 min after the arrival of paramedics. Based on the injury status and physical findings, he was diagnosed with traumatic asphyxia. Therapeutic hypothermia was performed and his level of consciousness gradually improved, after which he was transferred to another hospital on hospitalization day 57. There have been few reports of resuscitation ≥60 min after an initially detected rhythm of asystole. In case reports of therapeutic hypothermia performed for cardiac arrest due to traumatic asphyxia, which is occasionally seen, patients who returned to work exhibited the rapid return of spontaneous circulation. Our case suggests the possibility of successful resuscitation even after prolonged cardiac arrest in cases of traumatic asphyxia and the effectiveness of therapeutic hypothermia. We report our case considering additional case reports.